Surgery for bladder cancer

Most people with bladder cancer will have surgery. The type of surgery you have depends mainly on the size and location of the tumour, the stage of the cancer, if you have more than one tumour and if doctors think the cancer can be removed with surgery (is resectable). When planning surgery, your healthcare team will also consider other factors, such as your age and overall health.

Surgery may be done for different reasons. You may have surgery to:

completely remove the tumour

remove as much of the tumour as possible (debulk) before using other treatments

reduce pain or ease symptoms (palliative treatment)

When possible, doctors will try to do bladder-sparing surgery such as a transurethral resection (TUR) or a partial cystectomy. These surgeries try to keep as much of the bladder as possible so you can urinate normally. These surgeries may be a treatment option for some people who cannot have, or do not want to have, more aggressive surgery, such as a radical cystectomy. The healthcare team monitors people who have bladder-sparing surgery to see if the cancer recurs (comes back). People who have this type of surgery may also have additional treatment with immunotherapy, chemotherapy or radiation therapy.

The following are the types of surgery most often used to treat bladder cancer. You may also have other treatments before or after surgery.

Transurethral resection (TUR)

A transurethral resection (TUR) is also called a cystoscopic resection or a transurethral resection of bladder tumour (TURBT). It is used as the first treatment for all bladder cancers. It may be the only treatment needed for bladder cancer that hasn’t grown into the muscle layer of the bladder wall. For bladder cancer that has grown deeper into the bladder wall, a TUR usually removes most of the tumour and also acts as a biopsy before other treatment is given.

A TUR is done in a hospital. A local, spinal or general anesthesic is given before the surgery. With a general anesthetic, you will be unconscious.

The surgeon passes a cystoscope (a thin, rigid tube with a light and lens) through the urethra and into the bladder. The surgeon then uses a special instrument passed through the cystoscope to remove the tumour along with a margin of normal tissue around it. The surgeon will also take a sample of tissue from the bladder wall. The sample is tested to see if the cancer has grown into the muscle layer of the bladder wall.

The surgeon burns the area from where the tumour was removed with a high-energy electric current (called fulguration) or a laser. This procedure seals off blood vessels and destroys any remaining cancer.

Partial cystectomy

A partial, or segmental, cystectomy removes the tumour and part of the bladder around it. This surgery may be a treatment option for some people, but it is not commonly done. It may be an option if:

you only have one small tumour that can easily be removed with clear margins (there are no cancer cells in the normal tissue around the tumour that was removed along with the tumour)

the tumour is in an abnormal pouch on the bladder wall (called a diverticulum)

you aren’t healthy enough to have more extensive surgery

A partial cystectomy is usually considered for high-grade T1 tumours, which means the tumour has grown into the connective tissue (called the lamina propria) but has not spread to the muscle of the bladder wall. It is also considered for small T2 tumours, which means the tumour has grown into the muscle layer of the bladder wall.

Urachal cancer may also be treated with a partial cystectomy. Urachal cancer is a tumour that grows at the very top of the bladder from the urachus, which is a fibrous part left over from a passage for urine in the fetus.

A partial cystectomy is done in a hospital under a general anesthetic (you will be unconscious).

The surgeon makes a cut, or incision, in the abdomen (called a laparotomy) above the bladder. The tumour is removed along with a margin of healthy bladder tissue around it. The surgeon will do a pelvic lymph node dissection (PLND) to remove the pelvic lymph nodes because cancer may have spread to them. The cut is closed with stitches.

Radical cystectomy

A radical cystectomy removes all of the bladder along with surrounding fatty tissue and nearby lymph nodes. Some reproductive organs may also be removed. In men, the prostate gland, seminal vesicles and part of the urethra may be removed (called a radical cystoprostatectomy). In women, the uterus, cervix, fallopian tubes, ovaries, front wall of the vagina and urethra may be removed (called an anterior pelvic exenteration). This surgery is done when:

The tumour has grown into the muscle layer of the bladder wall. This is the most common use of a radical cystectomy.

Tumours keep coming back in the lining of the bladder after a TUR and intravesical immunotherapy or chemotherapy, especially if they are high grade.

The tumour can’t be removed with a TUR or a partial cystectomy because it has spread to a large area of the bladder or because there is more than one tumour.

A radical cystectomy is done in a hospital under a general anesthetic. The surgeon makes a cut, or incision, in the abdomen (called a laparotomy). In some cases, the surgeon makes small cuts so special instruments can be used to do the surgery (called laparoscopic surgery). The bladder is removed along with other organs in the pelvis. The surgeon will do a pelvic lymph node dissection (PLND) to remove lymph nodes in the pelvis where cancer may have spread.

Urinary diversion

If the bladder is removed, the surgeon needs to create a new pouch to hold urine and a new way for urine to leave the body. This type of reconstructive surgery is called a urinary diversion.

Urinary diversions can be either incontinent (the person can’t control urination) or continent (the person can control urination). In rare cases, a urinary diversion may be done without removing the bladder to relieve blocked urine flow if the cancer has spread or cannot be removed by surgery.

Incontinent diversion

With an incontinent diversion, urine is collected in a small bag worn on the outside of the body. This type of diversion is used more often for people who are older or in poor health.

The main type of incontinent diversion is an ileal conduit, or ileal loop, procedure. The surgeon removes a piece of the small or large intestine and uses it as a passageway, or conduit. The ureters are surgically attached to the conduit. The conduit is attached to an opening (called a stoma) in the abdominal wall. The stoma is called a urostomy. Urine drains from the kidneys, through the ureters, into the conduit and then through the stoma. The urine is collected in a small bag attached to the stoma and worn on the outside of the body.

Continent diversion

With a continent diversion, the surgeon creates a reservoir, or pouch, to store urine. The 2 main types of continent diversion are Indiana pouch and orthotopic neobladder.

Indiana pouch

With an Indiana pouch, the surgeon creates a reservoir using the right colon and part of the small intestine. The reservoir is connected to an opening (called a stoma) in the abdominal wall but there is no spontaneous drainage through this stoma and you don’t need to wear an external bag outside the body.

Someone with this type of urinary diversion needs to drain the reservoir with a tube, or catheter, 4–6 times throughout the day.

Orthotopic neobladder

With an orthotopic neobladder, the surgeon creates a reservoir (called a neobladder, or new bladder) using part of the small intestine. (In rare cases, part of the large intestine is used.) The ureters are attached to the reservoir and the reservoir is connected to the urethra.

Someone with this type of urinary diversion can urinate normally. The person empties the reservoir by relaxing muscles in the pelvic floor and increasing pressure in the abdomen. There is no need for an external bag or to empty the reservoir with a tube, or catheter.

This surgery cannot be done if the bladder cancer is too close to the urethra where the reservoir will be connected. It is also a more difficult surgery with a higher risk for complications, so it is not typically done in older people or those with other serious medical problems.